understanding tbi and one model state program

Traumatic Brain Injury among Children and Youth: Understanding TBI and One Model State Program

February 21, 2019

Funding Sponsor

This project is supported by the Health Resources and Services

Administration (HRSA) of the U.S. Department of Health and

Human Services (HHS) under the Child and Adolescent Injury and

Violence Prevention Resource Centers Cooperative Agreement

(U49MC28422) for $5,000,000 with 0 percent financed with

non-governmental sources. This information or content and

conclusions are those of the author and should not be construed

as the official position or policy of, nor should any endorsements

be inferred by HRSA, HHS or the U.S. Government.

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Presenters

Diane Sartanowicz

MS, LAT, ATC

Terrence R. Love

MS, CPC

Kristen Teipel

BSN, MPH

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Concussion 101Massachusetts Concussion Management Coalition

Science, education, and community working together to prevent and manage concussions

Diane Sartanowicz MS, LAT, ATC

Director

MASSACHUSETTS CONCUSSION MANAGEMENT COALITION

ObjectivesTraumatic brain injuries(TBI’s) and concussions

Define concussion

Diagnosing a concussion

Examination, testing, imaging

Prognosis/Outcomes of concussions

Prevention


TBI’s•Traumatic brain injury represents 30% of all injury deaths

•Every day, 153 people in the USA die from injuries that include TBI

•Most TBIs are mild “concussions”

•7-13% of patients with concussions develop post concussive syndrome

Taylor CA, CDC 2017


TBI-Related Hospital VisitsCDC Reports:

•2.5 Million Emergency Department Visits

•282,000 TBI-Related Hospitalizations

This represented approximately 1.9 % of all hospital emergency room and hospital admissions during the year 2013.

Taylor CA, CDC 2017


Not Just for Sports…Causes of TBI's

MVA (17.3%)

Unknown (21%)

Struck by Object (16.5)

Assault (10%)

Falls (35.2)

Centers for Disease Control and Prevention.http://www.cdc.gov/TraumaticBrainInjury/


Defining Concussion5th International Conference on Concussion in Sport

“Traumatic brain injury induced by biomechanical forces”◦ Direct blow to head/face or “impulsive” force transmitted

◦ Usually rapid onset of short-lived impairment of neurologic function that resolves spontaneously◦ May develop over minutes to hours

◦ Acute symptoms reflect functional rather than structural injury◦ No abnormality on standard structural neuroimaging is seen

◦ Range of clinical signs and symptoms may or may not involve LOC◦ Resolution of the clinical and cognitive features typically follows a sequential course


Diagnosing ConcussionScenarios:

1. Often easy: ◦ identifiable injury with immediate onset of symptoms

2. Many are much more difficult:◦ Multiple smaller hits

◦ Delayed symptom onset

3. Most difficult:◦ Collection of “new” sxs without identifiable injury

◦ Symptoms retroactively assigned to “injury”


Sideline Assessment


BESS (modified BESS)Procedure

◦ 3 stances (firm, foam)◦ Double leg

◦ Single leg (non-dominant)

◦ Tandem (non-dominant in back)

◦ 20 second holds

◦ Count the number of errors


Errors◦ Opening eyes

◦ Removing hands from the iliac crest

◦ Stepping or falling out of position

◦ >30 degrees of hip abduction or flexion

◦ Lifting the forefoot or heel

◦ Remaining out of position > 5 seconds

VOMS


ExaminationImpact site: local trauma, contusion

General interaction◦ Responsiveness, mood, affect, speech patterns

Cervical Evaluation◦ Bony and soft tissue tenderness, ROM

Neurologic exam◦ SCAT5◦ CN II-XII, reflexes◦ Romberg, Finger-to-nose testing◦ Extremity strength◦ Balance testing (modified BESS)◦ VOMS testing

Almost always completely normal


Subjective Symptom Scale


Management

Danger v.s. How you feel Three central principles

Prevent new injury

Minimize school interruption

Prevent deconditioning

• (physical, social, psychological)


“Treat Grandma”DietHydrationSleepLight Exertion Stress

Use of ImagingUncommon to require imaging in concussion

◦ Useful only for finding structural changes

CT Scans◦ Loss of consciousness at time of injury

◦ Obvious neurologic deficit at initial exam

MRI◦ May be used in prolonged symptoms (>4 weeks)


ImPACT Testing12yo+

◦ Pediatric ImPACT 5-11yo

Significant limitations◦ Baseline setting/effort

Overutilized as a “status report”◦ Ideal use is for clearance, when symptom free

Does NOT diagnose or clear on its own


PrognosisCDC’s Newest Predictive Numbers (positive) Centers for Disease Control and Prevention

Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children

◦ 70% - recover in 1 month

◦ 90% - recover in 3 months

◦ 95% - recover in 1 year

Predictors of longer symptoms (> 4 weeks)◦ Previous concussion history

◦ Previous anxiety/depression/ADHD

◦ Personal or family history of headaches/migraines

◦ Cognitive/“Foggy” feeling as worst symptoms

◦ Multiple collisions before removed (vs single blow)

◦ Females > males; High School > Professional


Repeat ConcussionsAthletes with history of concussion (Guskiewicz, JAMA 2003)

*1 injury = 1.5x risk for repeat concussion

*2 injuries = 2.8x risk for repeat concussion

*3+ injuries = 3.5x risk for repeat concussion


How Many is Too Many?No known answer – likely will never have one

◦ 2 in same season, recommend done for season

Varies based on age, level, future, etc.◦ Acceptance of risk…

◦ Based more on pattern and evidence of cumulative effects


Concussion PreventionAwareness of incoming injury

Cervical size and strength

Protective gearAt this point, we have no solid evidence that any piece of equipment has significant protection from concussion

◦ Helmets

◦ Headbands

◦ Mouthguards


References• McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport—the 5th international conference on

concussion in sport held in Berlin, October 2016. Br J Sports Med Published Online First: 26 April 2017.

• Halstead, ME, Walter, KD and THE COUNCIL ON SPORTS MEDICINE AND FITNESS. Clinical Report – Sport-Related Concussion in Children and Adolescents. Pediatrics 2010; 126 (3): published online Aug. 30, 2010.

• Harmon KG, Drezner JA, Gammons M Endorsed by the National Trainers’ Athletic Association and the American College of Sports Medicine, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med 2013;47:15-26.

• Meehan, WP and Bachur, R. Sport-Related Concussion. Pediatrics 2009; 123; (114-123).

• Mucha A, Collins MW, Elbin RJ, et al. A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions: Preliminary Findings. The American journal of sports medicine. 2014;42(10):2479-2486.

• Lumba-Brown A, Yeates KO, Sarmiento K, et al. Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children. JAMA Pediatrics Published online September 04, 2018.

• McCrea M, Guskiewicz K, Marshall S, et al. Acute Effects and Recovery Time Following Concussion in Collegiate Football Players. JAMA 2003;290(19):2556-2563.

• Taylor CA, Bell JM, Breiding MJ, Xu L. Traumatic Brain Injury–Related Emergency Department Visits, Hospitalizations, and Deaths —United States, 2007 and 2013. MMWR Surveill Summ 2017;66(No. SS-9):1–16.

• www.cdc.gov/concussion


http://www.cdc.gov/concussion

Thank YouMassachusetts Concussion Management Coalition

20 Hope Avenue, Suite G10

Waltham, MA 02453

781-216-3083

[email protected]

www.massconcussion.org

Like us on Facebook: @massconcussion

Follow us on Twitter: @MassConcussion


Terrence R. Love, MS, CPC

• Safety recognition program for youth sports organizations• Collaboration between the Tennessee Department of Health

and the Program for Injury Prevention in Youth Sports at Monroe Carell Junior Children’s Hospital at Vanderbilt

• Free and voluntary for all youth leagues and schools• Organizations may achieve Gold, Silver, or Bronze designation

Safe Stars’ goal is to standardize safety to protect young athletes

• Nearly 30 million children and adolescents participate in youth sports in the US

• More than 2.6 million children ages 0-19 years are treated in the ER for sports and recreation-related injuries

• In TN, there are approximately 35,000 youth sports-related ED visits each year

• According to the CDC, more than half of youth sports injuries are preventable

An athlete who sustains concussion is 4-6 times more likely to sustain a second concussion

10% of all contact-sport athletes sustain concussions yearly

Brain injuries associated with football occur at a rate of one in every 5.5 games

5% of soccer players sustain brain injuries

The head is involved in more baseball injuries than any other body part; almost half of injuries involve a child's head, face, mouth or eyes

National Safety Council: https://www.nsc.org/home-safety/safety-topics/child-safety/concussions

• On average, an estimated 66 athletes suffer sudden cardiac cause each year in the United States

• Sudden cardiac arrest (SCA) is the number one cause of death in the US for student athletes

• One study showed that 72% of students who died from SCA did have a warning sign

http://www.your-heart-health.com/content/close-the-gap/en-US/heart-disease-facts/young-athletes.html

• Survival rates decrease by 10% with each minute of delayed defibrillation

• 95% of sudden cardiac arrest victims die because of a delayed response

• Early defibrillation is critical in the event of a cardiac emergency – Goal: Defibrillate within 3 minutes from the time of collapse to

the first shock

Emergency Action Plan (EAP):

• Clear and detailed EAPs

• Practiced annually

• Have a plan for each practice and game site

• Make sure anyone could read and understand the plan

• Include plans for varying types of emergencies (medical, weather, etc.)

• Allergic conditions are the most common health issues affecting children in the U.S.

• Prompt recognition of the signs and symptoms of anaphylaxis is critical

• Kids can have allergic reactions even if they have no history of allergies

• According to the CDC, there is an average of 9,000 cases of heat illness among high school athletes annually

• During 2003–2012, lightning caused an average of 35 deaths per year in the United States

• Estimated that 1 in 4 children experience some form of child abuse or neglect in their lifetime

• 1 in 7 children have experienced abuse or neglect in the last year

• About 1,750 children died from abuse or neglect in 2016 in the United States

• Coaches spend a lot of time with children and it’s important that they have a plan in place for keeping children safe from abuse

https://www.cdc.gov/violenceprevention/childabuseandneglect/index.html

• Sports participation is the most common pathway for youth to engage in physical activity

• Physical activity improves morbidity, mortality and quality of life

• TN: Highest combined rate of childhood overweight & obesity in US (37.7% vs. 31% national average)

• Bronze is the initial level of recognition for Safe Stars

• A league must meet the following criteria:– Emergency Action Plan

– Background checks

– Minimum of 2 coaches CPR/AED certified

– AED on site

– Concussion and sudden cardiac death recognition/management

– Severe weather policy

– Anaphylaxis and Allergy Emergency plan

– Safeguarding/Abuse Prevention Policy

• Must meet all Bronze level criteria for recognition

• To achieve Silver or Gold, organizations must complete 2 or 4 additional criteria, respectively

• Additional criteria include:– Coaches complete additional health, safety and injury prevention

training

– All equipment undergoes safety checks

– Pre-participation physical exams required for all athletes

– Implement tobacco policy, “Young Lungs at Play”

– Medical professional on site for all games

– Medical professional on site for all practices

– Promote positive culture and standard of expectations

– Provide risk and safety information/policies to parents/guardians

Examples of promoting positive culture and standard of expectations concerning behavior• Implement a no bullying policy• All coaches and players complete the online bullying, hazing

and inappropriate behaviors course• Implement the “Coaching Boys into Men” program with

players

Examples of additional health, safety and injury prevention training• Suicide prevention training (QPR)• First aid training• PREPARE course – educates on recognizing symptoms of

dangerous conditions• Nutrition and hydration education

• Application link is located on the TDH Injury Prevention website; https://www.tn.gov/content/dam/tn/health/healthprofboards/Safe_Stars_Application.pdf

• Applicants are encouraged to read through the entire application before attempting to complete it

• Must upload certificates and other documents in application

• Resources listed on the Safe Stars website

• Recognition is valid for 5 years

https://www.tn.gov/content/dam/tn/health/healthprofboards/Safe_Stars_Application.pdf

• Signed certificate from the TDH Commissioner

• Safe Stars graphic to put on t-shirts, banners, stickers, etc.

• Recognition on the TDH website

• Parents may preferentially choose leagues and teams that value safety

• TN TBI Program housed within the Injury Detection and Prevention section

• TBI addressed in CDC Core SVIPP grant

• TBI Program participates in SVIPP meetings and provides TBI updates regularly to ICIG stakeholders

• Resources: TBI Program and Concussion webpages:

https://www.tn.gov/health/health-program-areas/fhw/vipp/tbi.html

https://www.tn.gov/health/health-program-areas/fhw/vipp/tbi/tennessee-concussion.html

https://www.tn.gov/health/health-program-areas/fhw/vipp/tbi.html

https://www.tn.gov/health/health-program-areas/fhw/vipp/tbi/tennessee-concussion.html

Strategies from CDC Core SVIPP grant:

• Disseminate best practice for Return to Play policy adherence to school and community athletic organizations

• Promote Return to Play training

resource to school and community

athletic organizations

• Survey coaches to determine

if RTP policies have changed

due to ongoing TDH education

efforts

• American Society of Shoulder and Elbow Therapists

• Belmont University Athletic Department

• Children’s Hospital Alliance of Tennessee

• Children’s Hospital at Erlanger

• Cumberland Pediatric Foundation

• East Tennessee Children’s Hospital

• LeBonheur Children’s Hospital

• Lipscomb University Athletic Department

• Memphis Grizzlies

• Monroe Carell Jr. Children’s Hospital at Vanderbilt

• Nashville Coaching Coalition

• Nashville Predators

• Nashville Soccer Club

• Nashville Sounds

• Nashville Sports Council

• National Football League Players Association

• Niswonger Children’s Hospital

• Office of Tennessee Attorney General

• Program for Injury Prevention in Youth Sports at Vanderbilt

• Safe Kids Cumberland Valley

• Special Olympics - Tennessee

• Tennessee Academy of Family Physicians

• Tennessee Association of Health, Physical Education, Recreation, and Dance

• Tennessee Athletic Trainers Society

• Tennessee Chapter of the American Academy of Pediatrics

• Tennessee Children's Emergency Care Alliance

• Tennessee Department of Economic and Community Development

• Tennessee Department of Health

• Tennessee Governor’s Children’s Cabinet (Kidcentraltn.com)

• Tennessee Medical Association

• Tennessee Nurses Association

• Tennessee Orthopedic Society

• Tennessee Osteopathic Medical Association

• Tennessee Recreation and Parks Association

• Tennessee Physical Therapy Association

• Tennessee Secondary School Athletic Association

• Tennessee State Soccer Association

• Tennessee Tech University Athletic Department

• University of Tennessee Athletic Department

• Vanderbilt University Athletic Department

• Vanderbilt Sports Medicine

• Vanderbilt University Medical Center

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Website Follow-upContact

WorkingApplications

Safe Stars Schools Safe StarsLeagues

Type of Safe Stars Contacts

1. Kingston Parks and Recreation Center2. Pride Lions Lacrosse3. Murfreesboro Parks and Recreation Center4. Gallatin Soccer Club5. Smyrna High School6. Central Magnet School7. Blackman High School8. Eagleville High School9. Siegel High School10. Riverdale High School11. LaVergne High School12. Oakland High School13. Stewarts Creek High School14. Gatlinburg-Pittman High School15. Northview Academy16. Seymour High School17. Sevier County High School18. Pigeon Forge High School

Measured Success

• Great partner support (internal & external)

• Program received widespread media attention for kickoff

• Infrastructure (model policies, website, staff support) in place

• Resources secured for AEDs

• Schools are starting to apply as TN Trainers Association has embraced the program

Challenges• Volunteer (or part-time)

league officials can be intimidated by the application process

• Leagues need policy development training before they apply – some lack policies

• Incentives could be more powerful. AEDs may not be the best for leagues

• Some legal concerns among schools and organizations (indemnity)

• Continue to work with TN TBI program and other partners to promote Safe Stars

• Work with the Tennessee Trainers Association to expand into more school districts

• Continue to learn from applicants regarding barriers and/or success with the program

• Work with partners to develop and implement program evaluation and publish results

Rachel Heitmann, MS

Injury Prevention Section Chief

615-741-0368

[email protected]

Terrence R. Love

Injury Prevention Manager

615-532-7778

[email protected]

mailto:[email protected]

mailto:[email protected]

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